Immediate Dentures Complete or removable partial denture fabricated for placement at the same appointment as extraction of natural teeth

Occlusion May be Mutilated Makes Jaw Relations Difficult

OVD, Midline & Incisal Edges May Require Change

After Extractions, Prior to Placement

Final Result

Immediate Complete Denture Conventional immediate denture intended to be relined to serve long-term Interim immediate denture (IID) (transitional): after healing a second new complete denture is fabricated as a long-term prosthesis (Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.1)

Advantages Maintenance of Appearance Circumoral support Muscle tone Occlusal vertical dimension Jaw relationships Facial height Tongue will not spread out as result of tooth loss Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.2.1

Advantages Less postoperative pain & bleeding extraction sites protected Pressure from denture base Easier to duplicate natural tooth shape & position (if desired) Easier Adaptation Speech, mastication rarely compromised Nutrition can be maintained Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2003. 9.2.1

Disadvantages More challenging to set teeth Less space for teeth as ridge resorption hasn’t occurred Alveolar ridge undercuts around remaining teeth may make impressions more difficult Unstable or inadequate occlusion can make recording centric position difficult Unstable Occlusion

Explanation to Patients Fit is usually not as good as traditional dentures (estimate ridge form) Extractions and sore spots from immediate denture can result in more discomfort after initial insertion Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2013. 9.4.3.1

Explanation to Patients Takes time to adapt to chewing and speaking Appearance may be unpredictable if anterior try-in not possible (Zarb, G. Prosthodontic Treatment for Edentulous Patients, 12th Edition. Elsevier, 2013. 9.4.3.1) No Anterior Try-in

Explanation to Patients Should be worn for first 24 hours without removal If removed, reinsertion can be difficult if significant swelling occurs Patient should return to dental office for initial removal at 24-hours

Explanation to Patients Immediate dentures will normally “loosen” during healing due to ridge resorption & soft tissue remodeling Relines/tissue conditioners will be required to improve the retention Normally a permanent reline will be required 4-6 months after insertion

Explanation to Patients In some cases a remake may be required Significant change in jaw position Significant esthetic problem May be cheaper/better to remake Patient is responsible for fees for relines Explain prior to beginning Include reline fee in estimate for immediate denture

Dalhousie Faculty of Dentistry Policy Immediate denture fee at Dalhousie includes tissue conditioner Additional fee for permanent reline of each denture

Dalhousie Protocols Online on Removable Prosthodontics Website http://removpros.dentistry.dal.ca/RemovSite/Immed_Dentures.html

Too Difficult No opposing occlusal contacts Severely collapsed occlusal vertical dimension Can’t register a repeatable jaw relationship (check at treatment planning appointment) Vestibule too short - vestibuloplasty would be required Refer

Dalhousie Protocols Sugery & Insertions Thursday afternoons only Book at least 2 weeks prior to surgery Book with Patient Services Staff Identify as a Immediate Dent at time of booking Only 2 immediate denture bookings per day Email Dr. Knechtel to advise him of booking date of booking # of teeth to be extracted CD (single or set) RPD

Dalhousie Protocols At least one week prior, students must review medical history & clinical surgical details with supervising surgeon At beginning of clinic inform both attending Surgeon and Dr. Knechtel that your patient has an immediate denture This ensures the patient moves to top of rotation, so that insertion is as early in clinic as possible

Dalhousie Protocols Students must see patient the day after delivery, Friday morning to ensure patient comfortable All immediate dentures insertions supervised by Dr. Knechtel.

Technique Examination/Diagnosis/Treatment Plan Informed consent Alternatives Pros/cons Prognosis Timing Costs

Examination/Diagnosis/Treatment Plan Beware of tissue undercuts Especially anterior maxilla & tuberosities Make notes to reduce at time of extractions Compress socket Bony reduction if necessary If not reduced, denture may not seat 2 piece tray for impression

Examination/Diagnosis/Treatment Plan Determine if OVD requires change at diagnosis appointment Use physiologic rest, interocclusal space measurements

Examination/Diagnosis/Treatment Plan To improve esthetics & ensure adequate stability: Decide whether you will need to imitate or change tooth arrangement prior to beginning Helps avoid unexpected surprises

Technique Oral hygiene procedures Reduce inflammation to speed healing Reduced discomfort after extractions Less soft tissue changes – better fit

Technique Preliminary extractions - posterior teeth Keep one set of opposing teeth on each side of arch if OVD and centric are to be preserved Wait 4 weeks for healing If very few teeth remain Consider extracting all at once Skip preliminary extraction step Less morbidity Extract All Teeth Single Appointment

Technique After Preliminary Extractions Preliminary impressions - alginate Final impressions – 1 or 2 step Jaw relation records Tooth set-up and try-in Final extractions and insertion Post insertion care

Examination/Diagnosis/Treatment Plan Reconfirm decision to imitate or change tooth arrangement Determine midlines, occlusal plane, vertical overlap, length of maxillary incisors Mark on cast for laboratory to use for setup

Preliminary impressions Stock trays Dentate or partially-edentulous Irreversible Hydrocolloid Mark vibrating line & hamular notches prior to impression Can’t reseat intraorally

Final Impressions Use 2 piece custom tray if significant undercuts If no large tissue undercuts use one piece custom tray

Mark Posterior Border Prior to Impression Vibrating line & hamular notches Not able to reseat intraorally tooth & tissue undercuts, embrasures If don’t have correct posterior border, denture will not be retentive

2 Piece Impression Stock Tray Custom Tray – Ensure Alginate Not Too Thin Stock Tray

1 Piece Impression Block out minor undercuts Ensure tray flange not too far from vestibule After border molding, should not lock into place

Jaw relation records Record base & occlusion rim used if unstable cast/contacts (wobbles, rocks) Make facebow record with dentate bitefork Use for centric & protrusion If stable contacts, record base not needed

Jaw Relation Records Determine OVD Use physiologic rest, interocclusal space measurements Do NOT incorporate an overbite in occlusion rims if anterior teeth are missing, use rims only to determine OVD, not incisal display Once mounted, determine overbite, incisal display required

Use occlusion rims for OVD, Jaw Relations Records

Centric Record Dentate Bitefork wth Wax/PVS Use PVS Bite Registration Material, NOT Wax

Tooth Set-up and Try-in Anterior Try-in Only Possible if Anterior Teeth Missing

Extraction and Insertion Have lab complete set up & modify cast as directed use probing depths & radiographs to guide cast modification

Do not create large socket convexities – grind teeth

Final Setup Usually will not allow for Full Wax Try-in

Extraction and Insertion Always request a surgical stent (guide) Prescribe fabrication of stent when sent for processing Allows for identifying areas of impingement (blanching)

Extraction and Insertion Extract teeth Prior to insertion, use surgical guide to assess ridge Place pressure but DONOT Flex during insertion check for over extensions, pressure (blanching) Seat the denture After stent show full seating, no blanching

Extraction and Insertion THE DENTURE MUST BE FULLY SEATED Otherwise occlusion will be unacceptable Once fully seated, adjust occlusion as needed Provide post insertion instructions Verbal Written – patient brochure

Dalhousie Timeline for Insertion 0 -15 min - Inform surgeon & Dr. Knechtel patient is receiving an immediate denture - review med history - provide local anaesthesia 15 - 60 min - extractions 1 - 2 hour - insert and adjust - instructions

Instructions to Patient Do not remove until 24 hour appointment If it comes loose/out replace immediately Soft/liquid diet for 24 hours Avoid vigorous rinsing Take analgesic as prescribed Expect red saliva

24 Hour Appointment Remove and clean denture Relieve sore spots Do not use PIP – use indelible stick Gross occlusal adjustment

1 Week Recall Appointment Relieve sore spots Use PIP Refine occlusion – possible remount

Continuing Care Tissue conditioner to improve retention as needed Remove any socket convexities to avoid healing defects Reline or remake in 4 to 6 months Postpone as long as patient can tolerate to ensure most of initial resorption complete

X X Remove denture base convexities to avoid healing defects X